Clinical Documentation Improvement Specialist Resume Samples

Description :

1. Identified all procedures and secondary diagnoses for comorbidities/complications and documents.
2. Identified documentation issues such as quality, appropriateness, completeness, and reimbursement issues and communicate these issues.
3. Queried the medical staff and other providers as necessary via written/verbal communication.
4. Ensured the timeliness of all written and verbal queries from providers to ensure proper documentation is obtained and placed in the medical record.
5. Educated physicians, clinicians, and other CDIS staff and coders regarding the necessity of providing complete and clear documentation.
6. The assessed skill level and competency of CDI staff by reviewing Working DRG versus final billed DRG.
7. Identified query opportunities missed by CDI staff, to obtain accurate and complete physician documentation.

Experience

5-7 Years

Level

Executive

Education

Certification

Description :

1. Prepare & coordinate CDS led Bi-weekly meetings for ICD-10 Physician Education.
2. Ability to discern the value of collecting marginal data against the potential administrative burden of obtaining additional specificity.
3. Initiate clinically relevant queries to physicians when documentation requires further specificity to accurately reflect the patients.
4. Working knowledge of 3M 360 Encoder, ICD-10 & Third-Party Payers respective reimbursement systems.
5. Conduct follow-up reviews every 2 days to support & assign a working or final DRG to be assigned upon patient discharge.
6. Work as part of a team that had a projected income revenue goal. Working together we were able to double that goal, with a quarterly earning of dollars.
7. Review medical records, identify missing or unclear information and then act as a point of contact with the Physician to fulfill the record deficit.

Experience

5-7 Years

Level

Executive

Education

Master Of Science

Description :

1. Accountable for improving the overall quality and completeness of clinical documentation at each facility.
2. Facilitates and obtains appropriate physician documentation for any clinical conditions or procedures to support the appropriate severity of illness.
3. Exhibits expert knowledge of clinical documentation requirements, DRG assignment, and clinical diagnoses & procedures.
4. Created and provided education for members of the patient care team regarding documentation guidelines.
5. Daily Assignments include: Completing the initial review of patient records within 24-48 hours of admission.
6. Evaluates documentation to assign the principal diagnoses, pertinent secondary diagnoses, and procedures for accurate DRG assignment.
7. Information is incomplete or missing then provides appropriate communication with assigned providers.

Experience

5-7 Years

Level

Executive

Education

Nursing

Description :

1. Responsible for detailed clinical review of patient records including coding principal diagnosis, comorbid conditions, and procedures.
2. Ensure the quality and completeness of clinical documentation through physician queries.
3. Facilitate complete, accurate, and specific documentation of diagnosis and level of services provided which is utilized for appropriate coding.
4. Utilize software to collect, track, and report outcomes.
5. Participate in the analysis and trending of statistical data to identify opportunities for improvement.
6. Assist with preparation of clinical documentation monitoring/trending reports for review with physicians and hospital leadership.
7. Educate physicians and other members of the patient care team regarding specific documentation needs, reporting and reimbursement issues.

Experience

2-5 Years

Level

Junior

Education

Nursing

Description :

1. Utilized Nursing knowledge and clinical experience, reviewed patient medical records for accuracy and specificity of clinical documentation.
2. Accessed and reviewed patient information via electronic data management systems for additional pertinent information.
3. Communicated with physicians via a query process to improve the quality of documentation within the patient record.
4. Maintained a computerized data form to track workflow and outcomes.
5. ICD-9 and CPT reference tools worked together with clinical coding staff to ensure the most accurate reporting/billing of patient accounts.
6. Gathered data for quality improvement in the Clinical Documentation Specialist, CDI process.
7. Identified variances from practice and policy and participate in the education of physician staff.

Experience

5-7 Years

Level

Executive

Education

Nursing

Description :

1. Review medical records concurrently for documentation improvement opportunities.
2. Work closely with physicians and case managers to educate on proper documentation.
3. Query physicians when there is an opportunity to improve documentation and capture CC and MCC's.
4. Improve case mix index and maximize hospital revenue.
5. Coding inpatient including heart and back procedures, same-day surgery accounts, ER records, outpatient accounts, skilled nursing facility accounts.
6. Special achievements: SPOT award: Award given for going above and beyond expected duties.
7. Operational Effectiveness award: Award given for increasing hospital revenue in six months and improving hospital case mix index.

Experience

5-7 Years

Level

Executive

Education

Business Administration

Description :

1. Assigned correct DRG/ICD-9 code and principal diagnosis extracted from clinical data.
2. Utilized 3M-HDM software encoder, data input, and to generate monthly reconciliation.
3. Created queries to physicians to clarify and specify needed documentation for correct reimbursement from Medicare and Blue Cross/Blue Shield.
4. Created letters for first-level appeals to Medicare and Blue Cross/Blue Shield.
5. Accessed Paragon EMR software for current clinical data information and HPF software for retrospective patient record information.
6. Achieved increased hospital reimbursements above the projected goal.
7. Ensure complete and accurate documentation is provided before discharge.
   

Experience

5-7 Years

Level

Executive

Education

Nursing

Description :

1. Present Review concurrent charts for necessary documentation for coding and DRG assignment.
2. Communicate with physicians to obtain additional documentation needed to capture complications and co-morbidities for optimal DRG.
3. Developed and implement a plan for both formal and informal education for physicians, nursing, and other clinical staff.
4. Identified strategies for changing work process to facilitate complete, accurate clinical documentation.
5. Ensured adherence to establish productivity target for record review.
6. created queries for medical records, edit database with replies from physicians.
7. Communicate with physicians either verbally or via query form to ensure documentation is clarified or corrected.

Experience

7-10 Years

Level

Management

Education

Management

Description :

1. Review concurrent inpatient accounts to ensure completeness and accuracy of services provided to the patients.
   
2. Assign the MS- DRG and look for documentation improvement opportunities.
3. Discuss each case with the physician and provide him/her with the tools to improve documentation.
4. Look for query opportunities to improve the SOI/ROM.
5. Worked with the coders and auditors to create a new template for the queries which are compliant with ICD-10.
6. Improving Health Quality Care through Better Clinical Documentation.
7. Built a CDI program in the smaller campus hospital.

Experience

2-5 Years

Level

Junior

Education

MD

Description :

1. Reviewed all inpatient records for complete and accurate documentation with regards to ICD-9 coding and MS-DRG specifications.
2. Maintain a close relationship with all physicians on staff to ensure adequate and specific documentation.
3. Developed coding queries for documentation.
4. Audited charts for governmental core measure requirements.
5. Utilized ICD-9 diagnosis coding, CPT, and E/M professional fee for the ER and outpatient services.
6. Familiar with CMS and commercial insurance requirements for payment.
7. Proficient with EMR documentation, 3M Encoder systems.

Experience

5-7 Years

Level

Executive

Education

Documentation

Description :

1. Inpatient and outpatient pre-surgical level of care reviews based on CMS and Interqual guidelines.
2. Process appeals for preadmission and presurgical denials.
3. Review of clinical documentation for consistency and accuracy throughout the stay.
4. Create queries and follow up with practitioners.
5. Educate practitioners on common queries and answer questions.
6. Advise of appropriate ICD-10 codes and CPT codes.
7. Assist and educate the preauthorization team as needed.

Experience

5-7 Years

Level

Executive

Education

Associates